Transcript Sub-theme-3- key not address _Dr .Kaushik

Prevention and control of communicable
and non- communicable diseases: Quality
improvement experiences
Dr Kaushik Ramaiya
CEO & Consultant Physician
Shree Hindu Mandal Hospital
Dar es Salaam
Presentation
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Introduction
Burden: Global and Tanzania
Health systems
What can be done?
Way forward
Non-Communicable Diseases:
A Global Priority
• NCDs = diabetes, cancer, cardiovascular and chronic respiratory
disease (WHO)
• 60% of global deaths
• Expanded to low and middle income countries
• Starting younger, not just rich and elderly
• Mostly preventable, effective treatments
• Catastrophic costs to government and individuals
• Successes in some cancers and cardiovascular
• Obesity and diabetes rising everywhere (320 million and will
reach 500 million by 2030)
Genesis of NCDs
UNDERLYING
SOCIOECONOMIC,
CULTURAL,
POLITICAL AND
ENVIRONMENTAL
DETERMINANATS
COMMON
MODIFIABLE
RISK FACTORS
INTERMEDIATE
RISK
FACTORS
MAIN CHRONIC
DISEASES
Unhealthy diet
Raised blood
pressure
Heart disease
Physical inactivity
Raised blood
glucose
Stroke
Globalization
Tobacco use
Abnormal blood
lipids
Cancer
Urbanization
NONMODIFIABLE
RISK FACTORS
Overweight/obesity
Chronic respiratory
diseases
Population ageing
Age
Early Life
Characteristics
Heredity
Diabetes
THE BURDEN
GLOBAL
Global Causes of Death
Chronic diseases:
Infectious diseases:
HIV/AIDS 4.9%
Tuberculosis 2.4%
Heart disease
30.2%
Malaria 1.5%
Total:
58.0M
Cancer
15.7%
Diabetes
1.9%
Other chronic diseases
15.7%
Other
Infectious
Diseases
20.9%
Injuries 9.3%
The total number of people
dying from chronic diseases is
double that of all infectious
diseases including HIV/AIDS,
tuberculosis and malaria (Nature,
2007).
Shifting Patterns of Global Health
Deaths, % of Total, 2005
Total
Deaths, M
Low
13.7
12.3
Lower-middle
2.5
13.2
Upper-middle
0.5
2.7
High
0.5
7.1
0
20
40
60
Infectious diseases
80 100
Forecast Deaths, 20062015, % Change
-10
Chronic diseases
-5
0
5
10
15
20
25
Ten leading causes of burden of disease,
world, 2004 and 2030
8
The burden of premature mortality from NCDs for both males and females is pronounced in
the WHO Africa Region
Percentage of premature deaths in Males
due to NCDs- 2012
9
Percentage of premature deaths in Females
due to NCDs- 2012
In the ECSA-HC region, NCDs represent a significant proportion of the mortality burden
Proportional mortality (% of total deaths, all ages, both sexes) 2012
100
90
80
70
60
50
40
30
20
10
0
Source: 10
WHO. Non communicable diseases country profiles 2014
Communicable Disease
NCD
Injuries
2025
55% of deaths in Africa
from NCDs and injuries
8%
17%
45%
30%
Group I - Communicable diseases, maternal, perinatal and nutritional conditions
Group II - Premature deaths from NCDs (below the age of 70), which are preventable
Group III - Other deaths from NCDs
Group IV - Injuries
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Projected Deaths from NCDs in the African Region in 2025
Yet only 3% of global
health aid ($21 billion)
goes to NCDs.
13th May 2010:
Everything Changed
UN Resolution
64/265
THE BURDEN
TANZANIA
National STEPS Survey, 2013
– Current smokers 14.1%
– Heavy episodic drinkers 20.4%
– Mean number of days fruits consumed 2.5
– Mean number of days vegetables consumed 4.5
– % with low level activity 7.5%
– % not engaging in vigorous activity 32.4%
– Overweight 26%
– Obese 8.7%
Burden – type 2 diabetes
• Prevalence in1980s:
– <1 % in rural population
– <2 % in urban population
– 5-6 % in special groups
– 9-12% in Asian Indian groups
• Prevalence in 2000:
– Approx 5% in urban population
• Prevalence in 2012:
– STEPS : 9%
Burden - Hypertension
• Prevalence in 1980s
– Rural population: 2-7%
– Urban population: 7-15%
– Special groups: 25-40%
• Prevalence in 2012
– STEPS : 26 %
– Known : 1.8%
Burden – other CVD risk factors
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Dyslipidaemia: 15-32%
Obesity: 12-36% (in rural areas: 5% to 25%)
Hypertension: 27-55%
IHD: no data but clinic records reveal
increasing trends
• Stroke: based on previous studies, incidence
increasing
Urbanisation- changes in selected risk
factors
Male
Female
90
40
80
35
70
30
25
50
Prevalence
Prevalence
60
40
30
20
20
15
10
10
5
0
Alcohol
Smoking
consumption
Risk factor
Physical
activity
0
Alcohol
Smoking
consumption
Risk factor
Source: Unwin et al, 2010. Rural to Urban migration and changes in cardiovascular risk factors
Physical
activity
Baseline
12 months
Cancers seen at ORCI
Years 2006 - 2011
Cancer Type
Cervical
Kaposi
Breast cancer
Esophageal
Head & neck
Lymphomas
Leukemias
Urinary bladder
Skin cancer
Eye cancers
Others
TOTAL
2006
955
295
244
181
155
201
46
46
40
46
598
2807
2007
1006
404
245
256
206
199
78
88
108
76
472
3138
2008 2009
1288 1374
418 447
275 322
282 307
244 272
226 245
87 103
87
98
111 123
80
95
382 390
3480 3776
Source: Ocean Road Cancer Institute
2010
1510
681
386
380
289
186
142
109
129
84
299
4195
2011 Increase
1881
2.0
814
2.8
526
2.2
511
2.8
361
2.3
269
1.3
261
5.7
153
3.3
141
3.5
119
2.6
208
0.3
5224
1.9
20
21
Road Traffic Accidents
• In period of six months (March-Sept, 2011), 2429 road
traffic injury victims were treated at MOI
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–
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36.5% were motorcycle crash injury victims
86.6% males
65% of the victims were between 20-40 years of age
72% extremity injuries
34.1% head injuries
50.3% collision between motorcycle and motor vehicle
27.4% Collison between motorcycle and pedestrian
44.9% used helmets – rider 68%, passenger 12.6%
49.9% possessed license
MOTORCYCLE CRASH: INJURIES PATTERN AND ASSOCIATED FACTORS AMONG PATIENTS TREATED AT MUHIMBILI ORTHOPAEDIC
INSTITUTE (MOI). Dr Bryson Mcharo, Dissertation, MUHAS, September, 2012.
Road Traffic Accidents: Risk factors
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Speed
– Pedestrians have a greater chance of surviving a car crash at 30 km/h or below
Drink driving
– The risk of being involved in a crash increases significantly above a blood alcohol concentration (BAC)
of 0.04 g/dl.
– Enforcing sobriety checkpoints and random breath testing can lead to reductions in alcohol-related
crashes of about 20% and have shown to be very cost-effective.
Motor cycle helmets
– Wearing a motorcycle helmet correctly can reduce the risk of death by almost 40% and the risk of
severe injury by over 70%.
Set belts and child restraints
– Wearing a seat-belt reduces the risk of a fatality among front-seat passengers by 40–50% and of
rear-seat passengers by between 25–75%.
– If correctly installed and used, child restraints reduce deaths among infants by approximately 70%
and deaths among small children by between 54% and 80%.
Distracted driving
– Text messaging also results in considerably reduced driving performance, with young drivers at
particular risk of the effects of distraction resulting from this use.
– Drivers using a mobile phone are approximately four times more likely to be involved in a crash than
when a driver does not use a phone. Hands-free phones are not much safer than hand-held phone
sets.
WHO Fact Sheet no. 358, 2015
Road Traffic Accidents – way forward
• Instruct the riders to undergo comprehensive
pre-riding course and be tested by traffic
police before possessing a riding license.
• Instruct the use of helmet during riding
• There is need of teaching the subject of Road
safety and use in primary school since
majority of the individuals ends up with
primary education.
Malaria
• Incidence: 19959 per 100000 population (2012)
• Death rate associated with malaria: 50 per
100000 population (2012)
• Children under 5 yrs age who slept under ITN the
previous night: 70% (2012)
• Proportion of pregnant women who received 2
doses of intermittent preventive treatment (IPT)
for malaria during their last pregnancy: 28%
(2012)
•
Africanhealthstats.org
Tuberculosis
• Case detection rate for TB: 79% (2013)
• Smear positive TB treatment success rate: 88%
(2011)
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Africanhealthstats.org
HIV / AIDS
• Proportion of adults and children living with
HIV/AIDS receiving ARTs : 37% (2013)
• Proportion of HIV positive pregnant women
receiving ARTs: 73% (2013)
• Proportion of HIV positive incident TB cases
receiving treatment for TB & HIV: 34% (2012)
• Proportion of pregnant women attending ANC
who were tested for HIV and know results: 86%
(2010)
•
Africanhealthstats.org
HIV and CVD
• Current evidence shows that that CVD risk
predictor algorithms developed in non-HIV
populations do not apply to HIV infected
individuals.
• They do not take into account HIV-related
features that likely contribute to CVD risks
including ART, chronic inflammation, and
immune activation.
•
CROI, 2015
Causes of Deaths in Males in DSM
Age 25-59: 1994-2002 n=634
Cause of death
Tuberculosis/AIDS
Acute Febrile Illness
% Cause of death
%
53.0 Acute abdominal conditions
1.3
All other specified communicable
8.8 diseases
1.3
Unintentional Injuries
8.8 All other specified NCDs
0.9
Undetermined
Cardiovascular Disorders
Neoplasms
Diabetes
8.2
5.2
2.4
2.2
Acute respiratory infections
Liver diseases
Central Nervous system disorders
Renal disorders
Chronic Obstructive Pulmonary
1.4 Disease
0.9
0.8
0.6
0.6
1.4 Tetanus
1.4
0.3
Intentional Injuries
All other symptoms, signs,
syndromes
Diarrhoeal diseases
0.3
Causes of Deaths in Females in DSM
Age 25-59: 1994-2002 n=666
Cause of death
Tuberculosis/AIDS
Undetermined
Cardiovascular Disorders
%
59.3
8.7
6.6
Cause of death
Diarrhoeal diseases
Eclampsia
Ante/postpartum haemorrhage
%
0.8
0.8
0.8
Acute Febrile Illness
6.5
Neoplasms
4.1
Chronic Obstructive Pulmonary 0.8
Disease
All other specified NCDs
0.6
Unspec. direct maternal causes 2.7
Acute abdominal conditions
0.6
Unintentional Injuries
Acute respiratory infections
2.3
1.8
0.6
0.6
All other spec. symptoms,
signs, syndromes
Central Nervous system
1.2
Anaemia
All other spec. communicable
diseases
Diabetes
0.9
0.6
Burden of CD and NCD in Tanzania: Proportional Mortality(% of
all total deaths, all ages, both sexes) 2012
Total deaths: 403,000: NCDs are estimated to account for 31% of total deaths
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Source: WHO: NCD Country profiles, 2014
Diabetes Economic Impact Study
Mental Illnesses (2009-10)
(ever diagnosed, self-reported)
(3.3)
Depression
Cntl
DM
(2.7)
Other Mental
Condition
0.0%
2.0%
4.0%
6.0%
8.0%
Diabetes Economic Impact Study (2009-2010)
Use of Hospitals, percentage or mean usages person, last
90 days
(4.0)
Percent with Any
Hospital Use
# Overnight
Admissions
(4.2)
(4.7)
# Casualty Ward
Admissions
(9.1)
# Outpatient
Visits
(7.4)
# Medication
Visits
0.0
0.5
1.0
1.5
2.0
2.5
Cntl
DM
Medical payment sources amongst people with
diabetes (n=2139)
%
Paid from own income
Paid from social support fund
Paid from donations
Paid from money from family or friends
79.2
13.6
1.3
35.1
Paid from money borrowed
Paid by selling possessions
Paid by selling house or land
23.1
3.0
2.6
Proportion of survey respondents who experienced catastrophic health
spending and distress financing following CVD-related hospitalization
divided by income strata, (2009-10)
HEALTH SYSTEMS
WHO Health systems framework
Human Resources for Health – Sub Saharan
Africa
• WHO recommendation (African Health Workforce
Observatory, 2009):
– For African countries to reach Health Related MDGs:
Minimum of 1 medical doctor per 5000 population
and 2.3 nurses and midwives per 1000 population
• 24 percent of the global disease burden –
worsened by HIV/AIDS epidemic and now NCD
and NTD burden
• Served by only 3 percent of global health
workforce
Challenges of Care - Health system related
• Accessibility of care
– Long distances to the clinics
– Opening hours limited
• Lack of qualified healthcare providers:
– Quality of care less than optimal
• Availability of essential medicines
– Frequent shortages
– No proper equipment for monitoring and follow-up
• Affordability of care
– Cost of treatment and medicines out of reach for the majority of patients
– Additional financial burden due to high costs of transportation to the
clinic
Capacity of the health facility laboratories
Laboratory test
% of health facilities with
laboratory capacity to
perform the test (n=15)
Venous blood glucose
13.3
Capillary blood glucose
93.3
Glycosylated
hemoglobin
6.7
Lipid profile
26.7
Serum creatinine
33.3
Urinalysis
100
Proportion of patients screened for
complications in the last one year (n=411)
Procedure
Dilated eye examination
Blood pressure
Weight measurement
Urinalysis
ECG
Serum creatinine
Lipid profile
Foot examination
Dental examination
%
18.3
76.9
73.5
61.8
8.5
5.8
4.9
10.0
5.6
Problems that patients face in accessing care
(n= 411)
Problem
%
Clinics irregular/ inconvenient time
24.1
Can not afford transportation cost
61.3
Can not afford cost of medication
47.9
Can not afford cost of investigations
21.4
Lack of medications
41.4
Few health care providers
48.2
WHAT CAN BE DONE?
CAPACITY PYRAMID
Enable
effective
use of
Enable
effective
use of
Tools
require
Skills
require
Staff and Infrastructure
Enable
effective
use of
require
Structures, Systems and Roles
Target diseases
• Assess burden of disease (morbidity &
mortality)
• Is there existence of effective evidence based
interventions for disease and its risk factors ?
• CVD, Diabetes, Asthma, Epilepsy, Mental
Health, Cancer, SCD
Step wise approach to Implementation of
interventions (1)
• Phase 1: Conduct situation analyses to assess the
current status of chronic disease care at the country
level
– Health facilities: risk assessment, diagnostic facilities,
treatment, patient education and counselling
– Availability, affordability & cost of medicines
– Record keeping and HMIS
– Community perception
– Stakeholders analysis
Step wise approach to Implementation of
interventions (2)
• Phase 2: Interventions at global, regional, country
and local level
– Policies – new, reforms
– Development or adaptation of appropriate guidelines and
treatment protocols
– Education & counselling for the patient, family and
community
– Training of health care providers
– Procurement and supply of diagnostics, medicines and
disposables
– Advocacy and community empowerment
– Civil society
Step wise approach to Implementation of
interventions (3)
• Other activities
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–
–
–
Resource mobilisation
Stakeholders partnership
Integration with other models of care – HIV/AIDS, TB, RCH
WHO - PEN
Establishment of diabetes services
Clinic support
•
•
•
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•
•
•
•
Sphygmomanometer.
Stethoscope.
Glucometer.
Height & weight scale.
Opthalmoscope.
Snellens Chart.
Consumables (lab/drugs)
Diabetes register.
Training
• 5 days training
• Participants:
– Medical Officers
– Clinical Officers
– Nurses
– Laboratory technicians
Training provided (2003-2008)
Mo/Co Nurses
Lab
Tech
Health
facilities
IADCT
(WDF 02-31)
44
69
32
26
Mwanza
(WDF 05-102)
/DANIDA
34
27
21
18
Mara
Kagera
Shinyanga
(WDF 07-265)/
DANIDA
85
170
85
85
Total
163
266
138
129
Training Targets
Facility
Level
NCD Clinics
Specialty Clinics
Nutrition
Sensitization
Zonal
Referral
Hospitals
2 MO/AMO/CO 2 HCP RCH
2 Nurses
2 HCP TB/Leprosy
2 HCP Eye/Dental
2 HCP HIV/AIDS
Regional
Referral
Hospitals
2 MO/AMO/CO 2 HCP RCH
1 Regional 2 RHMTs
2 Nurses
2 HCP TB/Leprosy Nutritionist
2 HCP Eye/Dental
2 HCP HIV/AIDS
District
Hospitals
2 MO/AMO/CO 1 HCP RCH
1 District
1 CHMT
2 Nurses
1 HCP TB/Leprosy Nutritionist
1 HCP Eye/Dental
1 HCP HIV/AIDS
Health
Centers
1 MO/AMO/CO
1 Nurse
Dispensaries: Provided 5 copies of IEC Manual to each public dispensary
Other infrastructure support
• For all hospitals
– Height & Weight scales
– BP Machines
– Stethoscopes
– Glucose meters
– Snell’s Charts
– Direct Ophthalmoscopes
– Measuring tapes
– Monofilaments
– Tuning forks
For Zonal Referral hospitals
Diabetes Foot equipment:
- Vascular Doppler Recorder
- Neuropathy Analyser
- Plantar Pressure Strides System Pedography
Diabetes Eye equipment:
- Fundus Camera
- Slit Lamp
- Indirect Ophthalmoscope
- Laser Photocoagulation
• 127 NCD clinics established at the district, regional referral
and zonal referral hospitals countrywide till March, 2015.
ZONE
HEALTH PROVIDERS TRAINED IN EACH REGION
TOTAL
MAN
ARS
KLM
TAN
54
55
43
50
202
NURSES
61
63
56
69
249
NUTRITIONISTS
5
8
8
6
27
DSM
PWN
28
41
39
33
44
185
45
44
52
49
64
254
6
5
5
1
5
22
MBY
IRI
NJO
56
35
38
29
41
28
227
NURSES
60
31
40
37
45
30
243
NUTRITIONISTS
9
5
6
6
7
5
38
MWZ
SHY
KAG
MAR
GEI
SIM
MO/AMO/CO
23
15
18
22
7
12
97
NURSES
53
23
48
44
15
23
206
NUTRITIONISTS
18
10
20
10
8
8
74
NORTHERN MO/AMO/CO
EASTERN
MO/AMOCO
&
NURSES
SOUTHERN
NUTRITIONISTS
SOUTHERN
HIGHLANDS MO/AMO/CO
LAKE
TOTAL
LINDI MTW MOR
RUK RUV
KAT
1824
Training Curriculum for NCDs Developed &
Manuals Prepared
Principles of effective chronic diseases service
•
•
•
•
Leveraging
Progressive decentralization
Optimizing integration of services
Optimizing clustering of related services
Leveraging
• Cost effective services delivered first:
– IMCI, TB, Malaria, HIV/AIDS, MCH
• NCD services - limitations:
– Cost: services more costly
– Interventions more complex
– Package of services less cost effective
• Fixed costs in health system (Information
systems, governance, supply chain)
• Under utilization of HR and facilities
Chronic care decentralization and
integration
• Community: CHWs
– Acute care, chronic care, prevention
• Health Centers:
– Integrated chronic care, rehabilitation, prevention
• District & Hospitals: Advanced care
– TB, HIV, NCDs, Mental Health, rehabilitation
• Regional Referral hospitals: Specialist care
– TB, HIV, NCDs, Mental Health, rehabilitation
• Zonal Referral hospitals: super specialist services
Integration of chronic diseases services
Diabetes/NCDs
HIV/AIDS
Diagnosis
•History
•Clinical
•Laboratory
•History
•Clinical
•Laboratory
Counselling (VCT)
Counselling (adherence)
Counselling (nutritional)
•Diabetes Educators
•Family/Social support
•Nutritionist
•Counsellors
•Family/Social support
•Nutritionist
Monitoring (Laboratory)
•Blood glucose levels
•Glycosylated Hb
•Renal, lipid profiles
•Viral load
•CD4/CD8 count
•Hemogram,renal,lipid,liver,
glucose profiles
Treatment (life-long)
•Life-style
•Oral drugs
•Insulin
•Life-style
•ARVT- first line, second line, etc
Complications
•Acute – DKA,HONK,
hypoglycaemia
•Chronic – target organs
•Acute – PCP, RTI, GE,
meningitis, encephalitis
•Chronic – kidneys, liver, heart,
brain, skin, lypodystrophy, lipid
and metabolism
Integration of chronic diseases services
HIV/AIDS
Diabetes/NCD
Reception
Records/MIS
Counselling room
Laboratory
Doctor’s room
Pharmacy
Social support services and Home based care
How to look after people with long term
conditions
WAY FORWARD
Priorities
•
•
•
•
•
Complete government wide action on risk
factors
Sustained primary health care with prioritised
packages plus palliative and long term
caregivers
Surveillance and monitoring
Learning from and integration with HIV/AIDS,
TB, and malaria programmes
Governments, private sector, civil society, and
international organisations must all work
together
Best system for responding to NCDs in
LMIC
•
•
•
•
•
•
•
High level task force that is whole of government and whole of
society
Emphasis on public health and prevention with an emphasis on
structural changes
Patients TRULY in charge
Extensive use of community health workers
Extensive standardisation and use of protocols
Emphasis on primary care
Few hospitals and specialists—to avoid capture of resources
Where should the money be spent?
Future
60
60
50
50
40
40
% Effort
% Effort
Today
30
30
20
20
10
10
0
0
Primary
Secondary
Tertiary
Primary
Type of Prevention
Secondary
Tertiary
Progress has been made . . .
• 10 years ago, NCDs were not a public health
priority
– Compared to HIV/AIDS: ‘We feel overlooked’
– Education and awareness now more
prominent
. . . but we still have a long way to go
‘To improve outcomes, we must address
the people behind the disease’
• Build evidence on
psychosocial implications
of NCDs in Africa
• Develop innovative tools
and interventions
• Train more healthcare
providers
• Adjust our approach to
become patient-centred
MEETING WITH PATIENTS TO ESTABLISH THE TDA BRANCH